This chapter is from the book

This chapter is from the book

A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower
extremities every two hours. Which of the following outcome criteria would the nurse use?

A.

Body temperature of 99°F or less

B.

Toes moved in active range of motion

C.

Sensation reported when soles of feet are touched

D.

Capillary refill of < 3 seconds

2.

A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for
this client?

A.

Side-lying with knees flexed

B.

Knee-chest

C.

High Fowler’s with knees flexed

D.

Semi-Fowler’s with legs extended on the bed

3.

A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for
this client?

A.

Taking hourly blood pressures with mechanical cuff

B.

Encouraging fluid intake of at least 200mL per hour

C.

Position in high Fowler’s with knee gatch raised

D.

Administering Tylenol as ordered

4.

Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?

A.

Steak

B.

Cottage cheese

C.

Popsicle

D.

Lima beans

5.

A newly admitted client has sickle cell crisis. He is complaining of pain in his feet and hands. The nurse’s assessment findings
include a pulse oximetry of 92. Assuming that all the following interventions are ordered, which should be done first?

A.

Adjust the room temperature

B.

Give a bolus of IV fluids

C.

Start O2

D.

Administer meperidine (Demerol) 75mg IV push

6.

The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the
client to select?

A.

Roast beef, gelatin salad, green beans, and peach pie

B.

Chicken salad sandwich, coleslaw, French fries, ice cream

C.

Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie

D.

Pork chop, creamed potatoes, corn, and coconut cake

7.

Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities
would the nurse recommend?

A.

A family vacation in the Rocky Mountains

B.

Chaperoning the local boys club on a snow-skiing trip

C.

Traveling by airplane for business trips

D.

A bus trip to the Museum of Natural History

8.

The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which finding reinforces the diagnosis
of B12 deficiency?

A.

Enlarged spleen

B.

Elevated blood pressure

C.

Bradycardia

D.

Beefy tongue

9.

The body part that would most likely display jaundice in the dark-skinned individual is the:

A.

Conjunctiva of the eye

B.

Soles of the feet

C.

Roof of the mouth

D.

Shins

10.

The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would
be most indicative of the anemia?

A.

BP 146/88

B.

Respirations 28 shallow

C.

Weight gain of 10 pounds in six months

D.

Pink complexion

11.

The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following
statements by the client indicates a need for further teaching?

A.

“I will drink 500mL of fluid or less each day.”

B.

“I will wear support hose.”

C.

“I will check my blood pressure regularly.”

D.

“I will report ankle edema.”

12.

A 33-year-old male is being evaluated for possible acute leukemia. Which of the following findings is most likely related
to the diagnosis of leukemia?

A.

The client collects stamps as a hobby.

B.

The client recently lost his job as a postal worker.

C.

The client had radiation for treatment of Hodgkin’s disease as a teenager.

D.

The client’s brother had leukemia as a child.

13.

Where is the best site for examining for the presence of petechiae in an African American client?

A.

The abdomen

B.

The thorax

C.

The earlobes

D.

The soles of the feet

14.

The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most important?

A.

“Have you noticed a change in sleeping habits recently?”

B.

“Have you had a respiratory infection in the last six months?”

C.

“Have you lost weight recently?”

D.

“Have you noticed changes in your alertness?”

15.

Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?

A.

Oral mucous membrane, altered related to chemotherapy

B.

Risk for injury related to thrombocytopenia

C.

Fatigue related to the disease process

D.

Interrupted family processes related to life-threatening illness of a family member

16.

A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin
a new job upon graduation. Which of the following diagnoses would be a priority for this client?

A.

Sexual dysfunction related to radiation therapy

B.

Anticipatory grieving related to terminal illness

C.

Tissue integrity related to prolonged bed rest

D.

Fatigue related to chemotherapy

17.

A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor:

A.

Platelet count

B.

White blood cell count

C.

Potassium levels

D.

Partial prothrombin time (PTT)

18.

The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client’s platelet count currently
is 80,000. It will be most important to teach the client and family about:

A.

Bleeding precautions

B.

Prevention of falls

C.

Oxygen therapy

D.

Conservation of energy

19.

The client has surgery for removal of a Prolactinoma. Which of the following interventions would be appropriate for this client?

A.

Place the client in Trendelenburg position for postural drainage.

B.

Encourage coughing and deep breathing every two hours.

C.

Elevate the head of the bed 30°.

D.

Encourage the Valsalva maneuver for bowel movements.

20.

The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority
intervention for this client is:

A.

Measure the urinary output.

B.

Check the vital signs.

C.

Encourage increased fluid intake.

D.

Weigh the client.

21.

A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?

A.

Place the client in a sitting position.

B.

Administer acetaminophen (Tylenol).

C.

Pinch the soft lower part of the nose.

D.

Apply ice packs to the forehead.

22.

A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative
period for the nurse to take is:

A.

The blood pressure

B.

The temperature

C.

The urinary output

D.

The specific gravity of the urine

23.

A client with Addison’s disease has been admitted with a history of nausea and vomiting for the past three days. The client
is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?

A.

Glucometer readings as ordered

B.

Intake/output measurements

C.

Evaluating the sodium and potassium levels

D.

Daily weights

24.

A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and
toes. What would the nurses’ next action be?

A.

Obtain a crash cart.

B.

Check the calcium level.

C.

Assess the dressing for drainage.

D.

Assess the blood pressure for hypertension.

25.

A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in four months,
and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses
is of highest priority?

A.

Impaired physical mobility related to decreased endurance

B.

Hypothermia r/t decreased metabolic rate

C.

Disturbed thought processes r/t interstitial edema

D.

Decreased cardiac output r/t bradycardia

26.

The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction
should be given to the client taking rosuvastatin (Crestor)?

A.

Report muscle weakness to the physician.

B.

Allow six months for the drug to take effect.

C.

Take the medication with fruit juice.

D.

Report difficulty sleeping.

27.

The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration,
the nurse should:

A.

Utilize an infusion pump.

B.

Check the blood glucose level.

C.

Place the client in Trendelenburg position.

D.

Cover the solution with foil.

28.

The six-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding
should be reported to the doctor?

A.

Blood pressure of 126/80

B.

Blood glucose of 110mg/dL

C.

Heart rate of 60bpm

D.

Respiratory rate of 30 per minute

29.

The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:

A.

Replenish his supply every three months.

B.

Take one every 15 minutes if pain occurs.

C.

Leave the medication in the brown bottle.

D.

Crush the medication and take with water.

30.

The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated
fats?

A.

Macaroni and cheese

B.

Shrimp with rice

C.

Turkey breast

D.

Spaghetti with meat sauce

31.

The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check
the:

A.

Feet

B.

Neck

C.

Hands

D.

Sacrum

32.

The nurse is checking the client’s central venous pressure. The nurse should place the zero of the manometer at the:

A.

Phlebostatic axis

B.

PMI

C.

Erb’s point

D.

Tail of Spence

33.

The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension.
The nurse should:

A.

Question the order.

B.

Administer the medications.

C.

Administer separately.

D.

Contact the pharmacy.

34.

The best method of evaluating the amount of peripheral edema is:

A.

Weighing the client daily

B.

Measuring the extremity

C.

Measuring the intake and output

D.

Checking for pitting

35.

A client with vaginal cancer is being treated with a radioactive vaginal implant. The client’s husband asks the nurse if he
can spend the night with his wife. The nurse should explain that:

A.

Overnight stays by family members is against hospital policy.

B.

There is no need for him to stay because staffing is adequate.

C.

His wife will rest much better knowing that he is at home.

D.

Visitation is limited to 30 minutes when the implant is in place.

36.

The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?

A.

Roast beef sandwich, potato chips, pickle spear, iced tea

B.

Split pea soup, mashed potatoes, pudding, milk

C.

Tomato soup, cheese toast, Jello, coffee

D.

Hamburger, baked beans, fruit cup, iced tea

37.

The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client
knows when the peak action of the insulin occurs?

A.

“I will make sure I eat breakfast within 10 minutes of taking my insulin.”

B.

“I will need to carry candy or some form of sugar with me all the time.”

C.

“I will eat a snack around three o’clock each afternoon.”

D.

“I can save my dessert from supper for a bedtime snack.”

38.

The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended
for the first two weeks of life because:

A.

New parents need time to learn how to hold the baby.

B.

The umbilical cord needs time to separate.

C.

Newborn skin is easily traumatized by washing.

D.

The chance of chilling the baby outweighs the benefits of bathing.

39.

A client with leukemia is receiving Trimetrexate. After reviewing the client’s chart, the physician orders Wellcovorin (leucovorin
calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:

A.

Treat iron-deficiency anemia caused by chemotherapeutic agents

B.

Create a synergistic effect that shortens treatment time

C.

Increase the number of circulating neutrophils

D.

Reverse drug toxicity and prevent tissue damage

40.

A four-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby
should receive:

A.

Hib titer

B.

Mumps vaccine

C.

Hepatitis B vaccine

D.

MMR

41.

The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:

A.

30 minutes before a meal

B.

With each meal

C.

In a single dose at bedtime

D.

30 minutes after meals

42.

A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate
action for the nurse to take?

A.

Call security for assistance and prepare to sedate the client.

B.

Tell the client to calm down and ask him if he would like to play cards.

C.

Tell the client that if he continues his behavior he will be punished.

D.

Leave the client alone until he calms down.

43.

When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level
of the umbilicus, and is displaced to the right. The next action the nurse should take is to:

A.

Check the client for bladder distention.

B.

Assess the blood pressure for hypotension.

C.

Determine whether an oxytocic drug was given.

D.

Check for the expulsion of small clots.

44.

A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night
sweats. The client’s symptoms are consistent with a diagnosis of:

A.

Pneumonia

B.

Reaction to antiviral medication

C.

Tuberculosis

D.

Superinfection due to low CD4 count

45.

The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed
for the client. Which of the following in the client’s history should be reported to the doctor?

A.

Diabetes

B.

Prinzmetal’s angina

C.

Cancer

D.

Cluster headaches

46.

The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal
irritation and spinal nerve root inflammation. A positive Kernig’s sign is charted if the nurse notes:

A.

Pain on flexion of the hip and knee

B.

Nuchal rigidity on flexion of the neck

C.

Pain when the head is turned to the left side

D.

Dizziness when changing positions

47.

The client with Alzheimer’s disease is being assisted with activities of daily living when the nurse notes that the client
uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:

A.

Agnosia

B.

Apraxia

C.

Anomia

D.

Aphasia

48.

The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client
is experiencing what is known as:

A.

Chronic fatigue syndrome

B.

Normal aging

C.

Sundowning

D.

Delusions

49.

The client with confusion says to the nurse, “I haven’t had anything to eat all day long. When are they going to bring breakfast?”
The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response
would be best for the nurse to make?

A.

“You know you had breakfast 30 minutes ago.”

B.

“I am so sorry that they didn’t get you breakfast. I’ll report it to the charge nurse.”

C.

“I’ll get you some juice and toast. Would you like something else?”

D.

“You will have to wait a while; lunch will be here in a little while.”

50.

The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer’s disease. Which side effect is most often associated
with this drug?

A.

Urinary incontinence

B.

Headaches

C.

Confusion

D.

Nausea

51.

A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion
on the perineum. Which initial action is most appropriate?

A.

Document the finding.

B.

Report the finding to the doctor.

C.

Prepare the client for a C-section.

D.

Continue primary care as prescribed.

52.

A client with a diagnosis of HPV is at risk for which of the following?

A.

Hodgkin’s lymphoma

B.

Cervical cancer

C.

Multiple myeloma

D.

Ovarian cancer

53.

During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small
blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:

A.

Syphilis

B.

Herpes

C.

Gonorrhea

D.

Condylomata

54.

A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum
is:

A.

Venereal Disease Research Lab (VDRL)

B.

Rapid plasma reagin (RPR)

C.

Florescent treponemal antibody (FTA)

D.

Thayer-Martin culture (TMC)

55.

A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated
with HELLP syndrome?

A.

Elevated blood glucose

B.

Elevated platelet count

C.

Elevated creatinine clearance

D.

Elevated hepatic enzymes

56.

The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?

A.

The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.

B.

The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow.

C.

The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the
reflex hammer.

D.

The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the
wrist.

57.

A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor’s order should
the nurse question?

A.

Magnesium sulfate 4gm (25%) IV

B.

Brethine 10mcg IV

C.

Stadol 1mg IV push every 4 hours as needed prn for pain

D.

Ancef 2gm IVPB every 6 hours

58.

A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl
glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse’s assessment of this data
is:

A.

The infant is at low risk for congenital anomalies.

B.

The infant is at high risk for intrauterine growth retardation.

C.

The infant is at high risk for respiratory distress syndrome.

D.

The infant is at high risk for birth trauma.

59.

Which observation in the newborn of a diabetic mother would require immediate nursing intervention?

A.

Crying

B.

Wakefulness

C.

Jitteriness

D.

Yawning

60.

The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with
drug therapy. An expected side effect of magnesium sulfate is:

A.

Decreased urinary output

B.

Hypersomnolence

C.

Absence of knee jerk reflex

D.

Decreased respiratory rate

61.

The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse
would:

A.

Place her in Trendelenburg position.

B.

Decrease the rate of IV infusion.

C.

Administer oxygen per nasal cannula.

D.

Increase the rate of the IV infusion.

62.

A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?

A.

Alteration in nutrition

B.

Alteration in bowel elimination

C.

Alteration in skin integrity

D.

Ineffective individual coping

63.

The nurse is caring for a client with uremic frost. The nurse is aware that uremic frost is often seen in clients with:

A.

Severe anemia

B.

Arteriosclerosis

C.

Liver failure

D.

Parathyroid disorder

64.

The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34,
pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis?

A.

Alteration in cerebral tissue perfusion

B.

Fluid volume deficit

C.

Ineffective airway clearance

D.

Alteration in sensory perception

65.

The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would
cause the most concern? The client:

A.

Likes to play football

B.

Drinks carbonated drinks

C.

Has two sisters

D.

Is taking acetaminophen for pain

66.

The nurse working the organ transplant unit is caring for a client with a white blood cell count of 450. During evening visitation,
a visitor brings a basket of fruit. What action should the nurse take?

A.

Allow the client to keep the fruit.

B.

Place the fruit next to the bed for easy access by the client.

C.

Offer to wash the fruit for the client.

D.

Ask the family members to take the fruit home.

67.

The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with
a BP of 90/40. The initial nurse’s action should be to:

A.

Place the client in Trendelenburg position.

B.

Increase the infusion of normal saline.

C.

Administer atropine intravenously.

D.

Move the emergency cart to the bedside.

68.

The client admitted two days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse
indicates understanding of the management of chest tubes?

A.

Order a chest x-ray.

B.

Reinsert the tube.

C.

Cover the insertion site with a Vaseline gauze.

D.

Call the doctor.

69.

A client being treated with sodium warfarin (Coumadin) has a Protime of 120 seconds. Which intervention would be most important
to include in the nursing care plan?

A.

Assess for signs of abnormal bleeding.

B.

Anticipate an increase in the Coumadin dosage.

C.

Instruct the client regarding the drug therapy.

D.

Increase the frequency of neurological assessments.

70.

Which selection would provide the most calcium for the client who is four months pregnant?

A.

A granola bar

B.

A bran muffin

C.

A cup of yogurt

D.

A glass of fruit juice

71.

The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates
the understanding of magnesium toxicity?

A.

The nurse performs a vaginal exam every 30 minutes.

B.

The nurse places a padded tongue blade at the bedside.

C.

The nurse inserts a Foley catheter.

D.

The nurse darkens the room.

72.

The best size cathlon for administration of a blood transfusion to a six-year-old is:

A.

18 gauge

B.

19 gauge

C.

22 gauge

D.

20 gauge

73.

A client is admitted to the unit two hours after an explosion causes burns to the face. The nurse would be most concerned
with the client developing which of the following?

A.

Hypovolemia

B.

Laryngeal edema

C.

Hypernatremia

D.

Hyperkalemia

74.

The client has recently been diagnosed with diabetes. Which of the following indicates understanding of the management of
diabetes?

A.

The client selects a balanced diet from the menu.

B.

The client can tell the nurse the normal blood glucose level.

C.

The client asks for brochures on the subject of diabetes.

D.

The client demonstrates correct insulin injection technique.

75.

The client is admitted following cast application for a fractured ulna. Which finding should be reported to the doctor?

A.

Pain at the site

B.

Warm fingers

C.

Pulses rapid

D.

Paresthesia of the fingers

76.

The client with AIDS should be taught to:

A.

Avoid warm climates.

B.

Refrain from taking herbals.

C.

Avoid exercising.

D.

Report any changes in skin color.

77.

Which action by the healthcare worker indicates a need for further teaching?

A.

The nursing assistant ambulates the elderly client using a gait belt.

B.

The nurse wears goggles while performing a venopuncture.

C.

The nurse washes his hands after changing a dressing.

D.

The nurse wears gloves to monitor the IV infusion rate.

78.

The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT the nurse should:

A.

Apply a tourniquet to the client’s arm.

B.

Administer an anticonvulsant medication.

C.

Ask the client if he is allergic to shell fish.

D.

Apply a blood pressure cuff to the arm.

79.

The five-year-old is being tested for enterobiasis (pinworms). Which symptom is associated with enterobiasis?

A.

Rectal itching

B.

Nausea

C.

Oral ulcerations

D.

Scalp itching

80.

The nurse is teaching the mother regarding treatment for pedicalosis capitis. Which instruction should be given regarding
the medication?

A.

Treatment is not recommended for children less than 10 years of age.

B.

Bed linens should be washed in hot water.

C.

Medication therapy will continue for one year.

D.

Intravenous antibiotic therapy will be ordered.

81.

The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?

A.

The client with HIV

B.

The client with a radium implant for cervical cancer

C.

The client with RSV (respiratory synctial virus)

D.

The client with cytomegalovirus

82.

The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?

A.

The client with methicillin resistant-staphylococcus aureas (MRSA)

B.

The client with diabetes

C.

The client with pancreatitis

D.

The client with Addison’s disease

83.

The doctor accidentally cuts the bowel during surgery. As a result of this action, the client develops an infection and suffers
brain damage. The doctor can be charged with:

A.

Negligence

B.

Tort

C.

Assault

D.

Malpractice

84.

Which assignment should not be performed by the nursing assistant?

A.

Feeding the client

B.

Bathing the client

C.

Obtaining a stool

D.

Administering a fleet enema

85.

The mother calls the clinic to report that her newborn has a rash on his forehead and face. Which action is most appropriate?

A.

Tell the mother to wash the face with soap and apply powder.

B.

Tell her that 30% of newborns have a rash that will go away by one month of life.

C.

Report the rash to the doctor immediately.

D.

Ask the mother if anyone else in the family has had a rash in the last six months.

86.

Which nurse should not be assigned to care for the client with a radium implant for vaginal cancer?

A.

The LPN who is six months postpartum

B.

The RN who is pregnant

C.

The RN who is allergic to iodine

D.

The RN with a three-year-old at home

87.

Which information should be reported to the state Board of Nursing?

A.

The facility fails to provide literature in both Spanish and English.

B.

The narcotic count has been incorrect on the unit for the past three days.

C.

The client fails to receive an itemized account of his bills and services received during his hospital stay.

D.

The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.

88.

The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge
nurse should:

A.

Call the Board of Nursing.

B.

File a formal reprimand.

C.

Terminate the nurse.

D.

Charge the nurse with a tort.

89.

The home health nurse is planning for the day’s visits. Which client should be seen first?

A.

The 78-year-old who had a gastrectomy three weeks ago and has a PEG tube

B.

The five-month-old discharged one week ago with pneumonia who is being treated with amoxicillin liquid suspension

C.

The 50-year-old with MRSA being treated with Vancomycin via a PICC line

D.

The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter

90.

The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency
department during the disaster?

A.

A client having auditory hallucinations and the client with ulcerative colitis

B.

The client who is pregnant and the client with a broken arm

C.

A child who is cyanotic with severe dypsnea and a client with a frontal head injury

D.

The client who arrives with a large puncture wound to the abdomen and the client with chest pain

91.

Before administering eardrops to a toddler, the nurse should recognize that it is essential to consider which of the following?

A.

The age of the child

B.

The child’s weight

C.

The developmental level of the child

D.

The IQ of the child

92.

The nurse is discussing meal planning with the mother of a two-year-old. Which of the following statements, if made by the
mother, would require a need for further instruction?

A.

“It is okay to give my child white grape juice for breakfast.”

B.

“My child can have a grilled cheese sandwich for lunch.”

C.

“We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch.”

D.

“For a snack, my child can have ice cream.”

93.

A client with AIDS has a viral load of 200 copies per ml. The nurse should interpret this finding as:

A.

The client is at risk for opportunistic diseases.

B.

The client is no longer communicable.

C.

The client’s viral load is extremely low so he is relatively free of circulating virus.

D.

The client’s T-cell count is extremely low.

94.

The client has an order for sliding scale insulin at 1900 hours and Lantus insulin at the same hour. The nurse should:

A.

Administer the two medications together.

B.

Administer the medications in two injections.

C.

Draw up the Lantus insulin and then the regular insulin and administer them together.

D.

Contact the doctor because these medications should not be given to the same client.

95.

A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:

A.

Altered nutrition

B.

Impaired communication

C.

Risk for injury/aspiration

D.

Altered urinary elimination

96.

What would the nurse expect the admitting assessment to reveal in a client with glomerulonephritis?

A.

Hypertension

B.

Lassitude

C.

Fatigue

D.

Vomiting and diarrhea

97.

Which action is contraindicated in the client with epiglottis?

A.

Ambulation

B.

Oral airway assessment using a tongue blade

C.

Placing a blood pressure cuff on the arm

D.

Checking the deep tendon reflexes.

98.

A 25-year-old client with a goiter is admitted to the unit. What would the nurse expect the admitting assessment to reveal?

A.

Slow pulse

B.

Anorexia

C.

Bulging eyes

D.

Weight gain

99.

Which of the following foods, if selected by the mother with a child with celiac, would indicate her understanding of the
dietary instructions?

A.

Whole-wheat toast

B.

Angel hair pasta

C.

Reuben on rye

D.

Rice cereal

100.

The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:

A.

Elevate the head.

B.

Recheck the O2 saturation in 30 minutes.

C.

Apply oxygen by mask.

D.

Assess the heart rate.

101.

Which observation would the nurse expect to make after an amniotomy?

A.

Dark yellow amniotic fluid

B.

Clear amniotic fluid

C.

Greenish amniotic fluid

D.

Red amniotic fluid

102.

The client taking Glyburide (Diabeta) should be cautioned to:

A.

Avoid eating sweets.

B.

Report changes in urinary pattern.

C.

Allow three hours for onset.

D.

Check the glucose daily.

103.

The obstetric client’s fetal heart rate is 80–90 during the contractions. The first action the nurse should take is:

A.

Reposition the monitor.

B.

Turn the client to her left side.

C.

Ask the client to ambulate.

D.

Prepare the client for delivery.

104.

Arterial ulcers are best described as ulcers that:

A.

Are smooth in texture

B.

Have irregular borders

C.

Are cool to touch

D.

Are painful to touch

105.

A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?

A.

Anticipate the need for a Caesarean section.

B.

Apply an internal fetal monitor.

C.

Place the client in Genu Pectoral position.

D.

Perform an ultrasound.

106.

A vaginal exam reveals that the cervix is 4cm dilated, with intact membranes and a fetal heart tone rate of 160–170bpm. The
nurse decides to apply an external fetal monitor. The rationale for this implementation is:

A.

The cervix is closed.

B.

The membranes are still intact.

C.

The fetal heart tones are within normal limits.

D.

The contractions are intense enough for insertion of an internal monitor.

107.

The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for
the primagravida as she completes the early phase of labor?

A.

Impaired gas exchange related to hyperventilation

B.

Alteration in placental perfusion related to maternal position

C.

Impaired physical mobility related to fetal-monitoring equipment

D.

Potential fluid volume deficit related to decreased fluid intake

108.

As the client reaches 6cm dilation, the nurse notes late decelerations on the fetal monitor. What is the most likely explanation
of this pattern?

A.

The baby is sleeping.

B.

The umbilical cord is compressed.

C.

There is head compression.

D.

There is uteroplacental insufficiency.

109.

The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:

A.

Notify her doctor.

B.

Start an IV.

C.

Reposition the client.

D.

Readjust the monitor.

110.

Which of the following is a characteristic of an ominous periodic change in the fetal heart rate?

A.

A fetal heart rate of 120–130bpm

B.

A baseline variability of 6–10bpm

C.

Accelerations in FHR with fetal movement

D.

A recurrent rate of 90–100bpm at the end of the contractions

111.

The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:

A.

The bladder fills more rapidly because of the medication used for the epidural.

B.

Her level of consciousness is such that she is in a trancelike state.

C.

The sensation of the bladder filling is diminished or lost.

D.

She is embarrassed to ask for the bedpan that frequently.

112.

A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that
conception is most likely to occur when:

A.

Estrogen levels are low

B.

Lutenizing hormone is high

C.

The endometrial lining is thin

D.

The progesterone level is low

113.

A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of
the rhythm method depends on the:

A.

Age of the client

B.

Frequency of intercourse

C.

Regularity of the menses

D.

Range of the client’s temperature

114.

A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most
suitable for the client with diabetes?

A.

Intrauterine device

B.

Oral contraceptives

C.

Diaphragm

D.

Contraceptive sponge

115.

The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of a ruptured ectopic
pregnancy?

A.

Painless vaginal bleeding

B.

Abdominal cramping

C.

Throbbing pain in the upper quadrant

D.

Sudden, stabbing pain in the lower quadrant

116.

The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the
nutritional needs of the pregnant client?

A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:

A.

Elevated human chorionic gonadatropin

B.

The presence of fetal heart tones

C.

Uterine enlargement

D.

Breast enlargement and tenderness

119.

The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:

A.

Hypoglycemic, small for gestational age

B.

Hyperglycemic, large for gestational age

C.

Hypoglycemic, large for gestational age

D.

Hyperglycemic, small for gestational age

120.

Which of the following instructions should be included in the nurse’s teaching regarding oral contraceptives?

A.

Weight gain should be reported to the physician.

B.

An alternate method of birth control is needed when taking antibiotics.

C.

If the client misses one or more pills, two pills should be taken per day for one week.

D.

Changes in the menstrual flow should be reported to the physician.

121.

The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client
with:

A.

Diabetes

B.

HIV

C.

Hypertension

D.

Thyroid disease

122.

A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s
first action should be to:

A.

Assess the fetal heart tones.

B.

Check for cervical dilation.

C.

Check for firmness of the uterus.

D.

Obtain a detailed history.

123.

A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that
labor has probably begun when:

A.

Her contractions are two minutes apart.

B.

She has back pain and a bloody discharge.

C.

She experiences abdominal pain and frequent urination.

D.

Her contractions are five minutes apart.

124.

The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic
is associated with babies born to mothers who smoked during pregnancy?

A.

Low birth weight

B.

Large for gestational age

C.

Preterm birth, but appropriate size for gestation

D.

Growth retardation in weight and length

125.

The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is
O positive. To provide postpartum prophylaxis, RhoGam should be administered:

A.

Within 72 hours of delivery

B.

Within one week of delivery

C.

Within two weeks of delivery

D.

Within one month of delivery

126.

After the physician performs an amniotomy, the nurse’s first action should be to assess the:

A.

Degree of cervical dilation

B.

Fetal heart tones

C.

Client’s vital signs

D.

Client’s level of discomfort

127.

A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client’s cervix
is 5cm dilated with 75% effacement. Based on the nurse’s assessment the client is in which phase of labor?

A.

Active

B.

Latent

C.

Transition

D.

Early

128.

A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include:

A.

Teaching the mother to provide tactile stimulation

B.

Wrapping the newborn snugly in a blanket

C.

Placing the newborn in the infant seat

D.

Initiating an early infant-stimulation program

129.

A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia,
the nurse should give priority to:

A.

Checking for cervical dilation

B.

Placing the client in a supine position

C.

Checking the client’s blood pressure

D.

Obtaining a fetal heart rate

130.

The nurse is aware that the best way to prevent post-operative wound infection in the surgical client is to:

A.

Administer a prescribed antibiotic.

B.

Wash her hands for two minutes before care.

C.

Wear a mask when providing care.

D.

Ask the client to cover her mouth when she coughs.

131.

The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?

A.

Pain

B.

Disalignment

C.

Cool extremity

D.

Absence of pedal pulses

132.

The nurse knows that a 60-year-old female client’s susceptibility to osteoporosis is most likely related to:

A.

Lack of exercise

B.

Hormonal disturbances

C.

Lack of calcium

D.

Genetic predisposition

133.

A two-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction. Which finding by the nurse
indicates that the traction is working properly?

The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse
should give priority to assessing the:

A.

Serum collection (Davol) drain

B.

Client’s pain

C.

Nutritional status

D.

Immobilizer

136.

Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates understanding
of the nurse’s teaching?

A.

“I must flush the tube with water after feedings and clamp the tube.”

B.

“I must check placement four times per day.”

C.

“I will report to the doctor any signs of indigestion.”

D.

“If my father is unable to swallow, I will discontinue the feeding and call the clinic.”

137.

The nurse is assessing the client with a total knee replacement two hours post-operative. Which information requires notification
of the doctor?

A.

Scant bleeding on the dressing

B.

Low-grade temperature

C.

Hemoglobin of 7gm

D.

The urinary output has been 120ml during the last hour

138.

The nurse is caring for the client with a five-year-old diagnosis of plumbism. Which information in the health history is
most likely related to the development of plumbism?

A.

The client has traveled out of the country in the last six months.

B.

The client’s parents are skilled stained-glass artists.

C.

The client lives in a house built in 1990.

D.

The client has several brothers and sisters.

139.

A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip
replacement with activities of daily living?

A.

High-seat commode

B.

Recliner

C.

TENS unit

D.

Abduction pillow

140.

An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of
anesthesia and narcotic administration, the nurse should:

A.

Administer oxygen via nasal cannula.

B.

Have narcan (naloxane) available.

C.

Prepare to administer blood products.

D.

Prepare to do cardioresuscitation.

141.

Which roommate would be most suitable for the six-year-old male with a fractured femur in Russell’s traction?

A.

16-year-old female with scoliosis

B.

12-year-old male with a fractured femur

C.

10-year-old male with sarcoma

D.

6-year-old male with osteomylitis

142.

A client with osteoarthritis has a prescription for Celebrex (celecoxib). Which instruction should be included in the discharge
teaching?

A.

Take the medication with milk.

B.

Report chest pain.

C.

Remain upright after taking for 30 minutes.

D.

Allow six weeks for optimal effects.

143.

A client with a fractured tibia has a plaster-of-Paris cast applied to immobilize the fracture. Which action by the nurse
indicates understanding of a plaster-of-Paris cast? The nurse:

A.

Handles the cast with the fingertips

B.

Petals the cast

C.

Dries the cast with a hair dryer

D.

Allows 24 hours before bearing weight

144.

The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response
would be best?

A.

“It will be alright for your friends to autograph the cast.”

B.

“Because the cast is made of plaster, autographing can weaken the cast.”

C.

“If they don’t use chalk to autograph, it is okay.”

D.

“Autographing or writing on the cast in any form will harm the cast.”

145.

The nurse is assigned to care for the client with a Steinman pin. During pin care, she notes that the LPN uses sterile gloves
and Q-tips to clean the pin. Which action should the nurse take at this time?

A.

Assisting the LPN with opening sterile packages and peroxide

B.

Telling the LPN that clean gloves are allowed

C.

Telling the LPN that the registered nurse should perform pin care

D.

Asking the LPN to clean the weights and pulleys with peroxide

146.

A child with scoliosis has a spica cast applied. Which action specific to the spica cast should be taken?

A.

Check the bowel sounds.

B.

Assess the blood pressure.

C.

Offer pain medication.

D.

Check for swelling.

147.

The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?

A.

Russell’s traction

B.

Buck’s traction

C.

Halo traction

D.

Crutchfield tong traction

148.

A client with a total knee replacement has a CPM (continuous passive motion device) applied during the post-operative period.
Which statement made by the nurse indicates understanding of the CPM machine?

A.

“Use of the CPM will permit the client to ambulate during the therapy.”

B.

“The CPM machine controls should be positioned distal to the site.”

C.

“If the client complains of pain during the therapy, I will turn off the machine and call the doctor.”

D.

“Use of the CPM machine will alleviate the need for physical therapy after the client is discharged.”

149.

A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker
is achieved if the:

A.

Palms rest lightly on the handles

B.

Elbows are flexed 0°

C.

Client walks to the front of the walker

D.

Client carries the walker

150.

When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:

A.

Attempt to replace the cord.

B.

Place the client on her left side.

C.

Elevate the client’s hips.

D.

Cover the cord with a dry, sterile gauze.

151.

The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room, a chest tube is inserted.
Which of the following explains the primary rationale for insertion of chest tubes?

A.

The tube will allow for equalization of the lung expansion.

B.

Chest tubes serve as a method of draining blood and serous fluid and assist in reinflating the lungs.

A client who delivered this morning tells the nurse that she plans to breastfeed her baby. The nurse is aware that successful
breastfeeding is most dependent on the:

A.

Mother’s educational level

B.

Infant’s birth weight

C.

Size of the mother’s breast

D.

Mother’s desire to breastfeed

153.

The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?

A.

The presence of scant bloody discharge

B.

Frequent urination

C.

The presence of green-tinged amniotic fluid

D.

Moderate uterine contractions

154.

The nurse is measuring the duration of the client’s contractions. Which statement is true regarding the measurement of the
duration of contractions?

A.

Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction.

B.

Duration is measured by timing from the end of one contraction to the beginning of the next contraction.

C.

Duration is measured by timing from the beginning of one contraction to the end of the same contraction.

D.

Duration is measured by timing from the peak of one contraction to the end of the same contraction.

155.

The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client
receiving intravenous Pitocin, the nurse should monitor for:

A.

Maternal hypoglycemia

B.

Fetal bradycardia

C.

Maternal hyperreflexia

D.

Fetal movement

156.

A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during
pregnancy?

A.

Insulin requirements moderate as the pregnancy progresses.

B.

A decreased need for insulin occurs during the second trimester.

C.

Elevations in human chorionic gonadotrophin decrease the need for insulin.

D.

Fetal development depends on adequate insulin regulation.

157.

A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:

A.

Providing a calm environment

B.

Obtaining a diet history

C.

Administering an analgesic

D.

Assessing fetal heart tones

158.

A primigravida, age 42, is six weeks pregnant. Based on the client’s age, her infant is at risk for:

A.

Down syndrome

B.

Respiratory distress syndrome

C.

Turner’s syndrome

D.

Pathological jaundice

159.

A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated
with:

A.

Magnesium sulfate

B.

Calcium gluconate

C.

Dinoprostone (Prostin E.)

D.

Bromocrystine (Parlodel)

160.

A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80;
deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100mL. The nurse should:

A.

Continue the infusion of magnesium sulfate while monitoring the client’s blood pressure.

Total Parenteral Nutrition is a high-glucose solution that often elevates the blood glucose levels.

D.

Total Parenteral Nutrition leads to further pancreatic disease.

211.

An adolescent primigravida who is 10 weeks pregnant attends the antepartal clinic for a first check-up. To develop a teaching
plan, the nurse should initially assess:

A.

The client’s knowledge of the signs of preterm labor

B.

The client’s feelings about the pregnancy

C.

Whether the client was using a method of birth control

D.

The client’s thought about future children

212.

An obstetric client is admitted with dehydration. Which IV fluid would be most appropriate for the client?

A.

.45 normal saline

B.

Dextrose 1% in water

C.

Lactated Ringer’s

D.

Dextrose 5% in .45 normal saline

213.

The physician has ordered a thyroid scan to confirm the diagnosis of a goiter. Before the procedure, the nurse should:

A.

Assess the client for allergies.

B.

Bolus the client with IV fluid.

C.

Tell the client he will be asleep.

D.

Insert a urinary catheter.

214.

The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse understands that RhoGam
is given to:

A.

Provide immunity against Rh isoenzymes

B.

Prevent the formation of Rh antibodies

C.

Eliminate circulating Rh antibodies

D.

Convert the Rh factor from negative to positive

215.

The nurse is caring for a client admitted to the emergency room after a fall. X-rays reveal that the client has several fractured
bones in the foot. Which treatment should the nurse anticipate for the fractured foot?

A.

Application of a short inclusive spica cast

B.

Stabilization with a plaster-of-Paris cast

C.

Surgery with Kirschner wire implantation

D.

A gauze dressing only

216.

A client with bladder cancer is being treated with iridium seed implants. The nurse’s discharge teaching should include telling
the client to:

A.

Strain his urine

B.

Increase his fluid intake

C.

Report urinary frequency

D.

Avoid prolonged sitting

217.

Following a heart transplant, a client is started on medication to prevent organ rejection. Which category of medication prevents
the formation of antibodies against the new organ?

A.

Antivirals

B.

Antibiotics

C.

Immunosuppressants

D.

Analgesics

218.

The nurse is preparing a client for cataract surgery. The nurse is aware that the procedure will use:

A.

Mydriatics to facilitate removal

B.

Miotic medications such as Timoptic

C.

A laser to smooth and reshape the lens

D.

Silicone oil injections into the eyeball

219.

A client with Alzheimer’s disease is awaiting placement in a skilled nursing facility. Which long-term plans would be most
therapeutic for the client?

A.

Placing mirrors in several locations in the home

B.

Placing a picture of herself in her bedroom

C.

Placing simple signs to indicate the location of the bedroom, bathroom, and so on

D.

Alternating healthcare workers to prevent boredom

220.

A client with an abdominal cholecystectomy returns from surgery with a Jackson-Pratt drain. The chief purpose of the Jackson-Pratt
drain is to:

A.

Prevent the need for dressing changes

B.

Reduce edema at the incision

C.

Provide for wound drainage

D.

Keep the common bile duct open

221.

The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect
to find the presence of:

A.

Mongolian spots

B.

Scrotal rugae

C.

Head lag

D.

Polyhydramnios

222.

The nurse is caring for a client admitted with multiple trauma. Fractures include the pelvis, femur, and ulna. Which finding
should be reported to the physician immediately?

A.

Hematuria

B.

Muscle spasms

C.

Dizziness

D.

Nausea

223.

A client is brought to the emergency room by the police. He is combative and yells, “I have to get out of here. They are trying
to kill me.” Which assessment is most likely correct in relation to this statement?

A.

The client is experiencing an auditory hallucination.

B.

The client is having a delusion of grandeur.

C.

The client is experiencing paranoid delusions.

D.

The client is intoxicated.

224.

The nurse is preparing to suction the client with a tracheotomy. The nurse notes a previously used bottle of normal saline
on the client’s bedside table. There is no label to indicate the date or time of initial use. The nurse should:

A.

Lip the bottle and use a pack of sterile 4×4 for the dressing.

B.

Obtain a new bottle and label it with the date and time of first use.

C.

Ask the ward secretary when the solution was requested.

D.

Label the existing bottle with the current date and time.

225.

An infant’s Apgar score is 9 at five minutes. The nurse is aware that the most likely cause for the deduction of one point
is:

A.

The baby is hypothermic.

B.

The baby is experiencing bradycardia.

C.

The baby’s hands and feet are blue.

D.

The baby is lethargic.

226.

The primary reason for rapid continuous rewarming of the area affected by frostbite is to:

A.

Lessen the amount of cellular damage

B.

Prevent the formation of blisters

C.

Promote movement

D.

Prevent pain and discomfort

227.

A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse’s response
is based on the knowledge that hemodialysis works by:

A.

Passing water through a dialyzing membrane

B.

Eliminating plasma proteins from the blood

C.

Lowering the pH by removing nonvolatile acids

D.

Filtering waste through a dialyzing membrane

228.

During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is
most appropriate?

A.

Administer an antibiotic.

B.

Contact the physician for an order for immune globulin.

C.

Administer an antiviral.

D.

Tell the client that he should remain in isolation for two weeks.

229.

A client hospitalized with MRSA is placed on contact precautions. Which statement is true regarding precautions for infections
spread by contact?

A.

The client should be placed in a room with negative pressure.

B.

Infection Requires close contact; therefore, the door may remain open.

C.

Transmission is highly likely, so the client should wear a mask at all times.

D.

Infection Requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown.

230.

A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response
by the nurse indicates understanding of phantom limb pain?

A.

“The pain will go away in a few days.”

B.

“The pain is due to peripheral nervous system interruptions. I will get you some pain medication.”

C.

“The pain is psychological because your foot is no longer there.”

D.

“The pain and itching are due to the infection you had before the surgery.”

231.

A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that during the Whipple procedure,
the doctor will remove the:

A.

Head of the pancreas

B.

Proximal third section of the small intestines

C.

Stomach and duodenum

D.

Esophagus and jejunum

232.

The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating:

A.

Fruits

B.

Salt

C.

Pepper

D.

Ketchup

233.

A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:

A.

Have a Protime done monthly.

B.

Eat more fruits and vegetables.

C.

Drink more liquids.

D.

Avoid crowds.

234.

The nurse is assisting the physician with removal of a central venous catheter. To facilitate removal, the nurse should instruct
the client to:

A.

Perform the Valsalva maneuver as the catheter is advanced

B.

Turn his head to the left side and hyperextend the neck

C.

Take slow, deep breaths as the catheter is removed

D.

Turn his head to the right while maintaining a sniffing position

235.

A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for:

A.

Allergies to pineapples and bananas

B.

A history of streptococcal infections

C.

Prior therapy with phenytoin

D.

A history of alcohol abuse

236.

The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:

A.

Using oil- or cream-based soaps

B.

Flossing between the teeth

C.

The intake of salt

D.

Using an electric razor

237.

The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:

A.

Apply the new tie before removing the old one.

B.

Have a helper present.

C.

Hold the tracheotomy with the nondominant hand while removing the old tie.

D.

Ask the doctor to suture the tracheostomy in place.

238.

The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should
give priority to:

A.

Turning the client to the left side

B.

Milking the tube to ensure patency

C.

Slowing the intravenous infusion

D.

Notifying the physician

239.

The infant is admitted to the unit with tetralogy of Fallot. The nurse would anticipate an order for which medication?

A.

Digoxin

B.

Epinephrine

C.

Aminophyline

D.

Atropine

240.

The nurse is educating the lady’s club in self-breast exam. The nurse is aware that most malignant breast masses occur in
the Tail of Spence. On the diagram, place an X on the Tail of Spence.